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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />New EH Program at Existin Facilit <br /> <br />ONew EH Pro ram and New Facility <br />Facility ID <br /> <br />Program Record ID <br /> <br />Facility Address <br />(Please check the appropriate description and specify size, number of units and pertinent information.) <br />FOOD PROGRAM (1600) <br />Restaurant: Seating Capacity Square Footage <br />Commissary 0 Dry storage only 0 with Food Preparation <br />Retail Market----Square footage w/Meat Market only <br />CI Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />,t1 Temporary Food Facility --Dates of operation from .1 -2_ 7- 2 -1 to 4 -2;9-21 <br />Special Event---Dates of operation from to <br />Registration # <br />License # Sticker # <br />DAIRY PROGRAM (2000) <br />Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser-Number of Containers in Multi-Head Unit <br /> <br />Hazardous Materials Business Plan (1900) Number of chemicals: <br />CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units CI Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />CI Abandoned HW Site El non-NPL/SEP Cleanup Site CI RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool <br /> <br />0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />ID Poultry Farm Maximum number of birds <br /> <br />CI Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) CI Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) CI Body Art Temp Event Co-ord (4130) 0 Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />CI Pumper VehicleRegistration # License # Capacity Vehicle # <br />CI Pumper Yard CI Package Treatment Plant CI Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />CI Landfill 0 Transfer Station <br />Waste Tire Facility CI Compost Facility <br />Refuse Vehicles (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care CI Skilled Nursing CI Large Generator 0 <br />Transfer Station 0 Veterinary Clinic 0 Common Storage Facility 0 2- 10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />CONTACT PERSON / A ( -vo e 1( Day Ph Night Ph <br />EMERGED CY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />PROGRAM ELEMENT It- , 5 FEE <br />INSPECTOR # PERMIT VALID1 Vt. 214 i 2.412ii <br />ElCheck # 2----+(( AMOUNT PAID (5P,— Date 9— <br />0 Surcharige FEE <br />to <br /> <br />Cash REVIEWED BY <br />48-02-034 <br />1 (iStiRd 0 U[14-01\76W 6: J-- 1/23/13 <br />Food Handlers Course required: YES 0 No 0 <br />CIVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />Sticker # <br />0 Ice Plant 0 Produce Stand <br />0 CFO 0 A CI B <br />Ag/Cannery Waste Site <br />Process/Recycle Facility <br />CI Dumpsters > 20 cu yd (# of Units) <br />CI Sludge/As ite <br />CI CIA Land <br />CI Farm/Ra <br />Small Generator 0 IOW?? klauler <br />0 11 - 60-41/06 60 geHe .airof <br />kisy 4Qui 14 N <br />r7 ekt Qviti 4pup,r}, <br />°P1110-4/1/. <br />ACCOUNTING OFFICE <br />Other FEE <br />Food Handler <br />INVOICE # <br />Date <-57M1 <br />MASTERFILE RECORD INFORMATION PINK